Question

Is unintended pregnancy associated with adverse maternal and infant health conditions during pregnancy and post partum in the US?

Findings

In this systematic review and meta-analysis, 36 studies (N = 524 522 participants) that controlled for multiple confounders compared health outcomes for intended vs unintended pregnancies. Unintended pregnancy was significantly associated with higher odds of maternal depression during pregnancy and post partum, maternal experience of interpersonal violence, preterm birth, and infant low birth weight.

Meaning

Unintended pregnancy, compared with intended pregnancy, was significantly associated with adverse maternal and infant outcomes.

Importance

Unintended pregnancy is common in the US and is associated with adverse maternal and infant health outcomes; however, estimates of these associations specific to current US populations are lacking.

Objective

To evaluate associations of unintended pregnancy with maternal and infant health outcomes during pregnancy and post partum with studies relevant to current clinical practice and public health in the US.

Data Sources

Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PsycINFO, SocINDEX, and MEDLINE databases (January 1, 2000, to June 15, 2022) and manual review of reference lists.

Study Selection

Epidemiologic studies relevant to US populations that compared key maternal and infant health outcomes for unintended vs intended pregnancies and met prespecified eligibility criteria were included after investigators’ independent dual review of abstracts and full-text articles.

Data Extraction and Synthesis

Investigators abstracted data from publications on study methods, participant characteristics, settings, pregnancy intention, comparators, confounders, and outcomes; data were validated by a second investigator. Risk of bias was independently dual rated by investigators using criteria developed by the US Preventive Services Task Force. Results of studies controlling for confounders were combined by using a profile likelihood random-effects model.

Main Outcomes and Measures

Prenatal depression, postpartum depression, maternal experience of interpersonal violence, preterm birth, and infant low birth weight.

Results

Thirty-six studies (N = 524 522 participants) were included (14 cohort studies rated good or fair quality; 22 cross-sectional studies); 12 studies used large population-based data sources. Compared with intended pregnancy, unintended pregnancy was significantly associated with higher odds of depression during pregnancy (23.3% vs 13.9%; adjusted odds ratio [aOR], 1.59 [95% CI, 1.35-1.92];I² = 85.0%; 15 studies [n = 41 054]) and post partum (15.7% vs 9.6%; aOR, 1.51 [95% CI, 1.40-1.70];I² = 7.1%; 10 studies [n = 82 673]), interpersonal violence (14.6% vs 5.5%; aOR, 2.22 [95% CI, 1.41-2.91];I² = 64.1%; 5 studies [n = 42 306]), preterm birth (9.4% vs 7.7%; aOR, 1.21 [95% CI, 1.12-1.31];I² = 1.7%; 10 studies [n = 94 351]), and infant low birth weight (7.3% vs 5.2%; aOR, 1.09 [95% CI, 1.02-1.21];I² = 0.0%; 8 studies [n = 87 547]). Results were similar in sensitivity analyses based on controlling for history of depression for prenatal and postpartum depression and on study design and definition of unintended pregnancy for relevant outcomes. Studies provided limited sociodemographic data and measurement of confounders and outcomes varied.

Conclusions and Relevance

In this systematic review and meta-analysis of epidemiologic observational studies relevant to US populations, unintended pregnancy, compared with intended pregnancy, was significantly associated with adverse maternal and infant outcomes.

Trial Registration

PROSPERO Identifier:CRD42020192981

Data Sources

A research librarian conducted searches of the Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PsycINFO, SocINDEX, and Ovid MEDLINE (January 1, 2000, to June 15, 2022) databases for relevant English-language articles published since 2000 (eMethods inSupplement). Investigators manually reviewed reference lists of key studies and systematic reviews.

Study Selection

Investigators independently dual reviewed abstracts and full-text articles to identify studies meeting prespecified eligibility criteria. Discrepancies were resolved by discussion and consensus. Published studies were eligible for the meta-analysis if they evaluated associations of unintended pregnancy with maternal and infant health outcomes occurring during pregnancy and post partum by comparing participants with unintended vs intended pregnancies and reported estimates that adjusted for confounders. Unintended pregnancy was determined by maternal self-report. To optimize applicability to US practice, eligible studies included populations in countries considered very high on the 2018 Human Development Index. While the search and eligibility criteria used an inclusive definition of women (ie, pregnant and postpartum populations that included all gender identities), studies referred to their populations as women. Investigators managed references in an EndNote database (Thomson Reuters).

Outcomes

Eligibility criteria for studies in the systematic review included a wide range of maternal and infant health outcomes occurring during pregnancy and post partum. However, studies of most outcomes could not be combined in meta-analysis because they were reported in single or a small number of studies, outcome measures were heterogeneous, or results were not controlled for confounders. Studies not eligible for the meta-analysis were not included in this article.

Studies provided adequate data for meta-analysis for 5 outcome measures including prenatal depression, postpartum depression, maternal experience of interpersonal violence, preterm birth (<37 weeks’ completed gestation), and infant low birth weight (<2500 g).

Data Extraction and Risk of Bias Assessment

Investigators (B.G.D., K.A., A.B.) abstracted data from included studies into tables including study design, methods, participant characteristics, settings, measure of pregnancy intention, comparators, confounders, and outcomes. Additional investigators (H.D.N., R.F.) reviewed data for accuracy. All data were extracted directly from publications, and contacting authors for additional information was not necessary. Risk of bias (quality) of cohort studies was independently dual rated as good, fair, or poor by investigators using criteria developed by the US Preventive Services Task Force (eMethods inSupplement).¹⁸ While these criteria are frequently used for systematic reviews for clinical guidelines, they do not apply to cross-sectional studies. Discrepancies were resolved through consensus with a third reviewer.

Data Synthesis

Results of included studies rated good or fair quality were combined using meta-analysis to obtain summary estimates of associations with the 5 maternal and infant health outcomes. Studies compared outcomes between 2 groups based on their definitions of unintended pregnancy and selection of comparison groups (unintended/intended; unplanned/planned; unwanted/wanted). For the primary meta-analysis, studies were combined using categories that most closely represented unintended pregnancy and were most consistent with definitions used across studies.

Adjusted odds ratios (aORs) from studies that adjusted for key confounding variables were included in the meta-analysis and no crude estimates were included. Adjusted risk ratios (aRRs) were reported in 2 studies^19,20 and converted to aORs. The aORs were combined by using a profile likelihood random-effects model to account for variation among studies.²¹ The presence of statistical heterogeneity among studies was assessed using Cochran χ² tests, and the magnitude of heterogeneity using theI² statistic.²¹ Heterogeneity was explored with sensitivity analyses based on study design (cross-sectional; cohort), whether the study controlled for history of depression for prenatal depression and postpartum depression outcomes, defined pregnancy as unwanted rather than unintended or unplanned, and provided separate outcomes for mistimed pregnancy. Unadjusted absolute risks were expressed as the proportions of participants in each group experiencing the outcome of interest for studies providing data. Overall absolute risks were calculated by combining proportions for individual studies. Studies not reporting data for absolute risks were not included in the overall estimates. Tests of small study effects were evaluated using the Egger test²² and funnel plots for outcomes with at least 10 studies. Analyses were performed using Stata/SE version 16.1 (StataCorp). All significance testing was 2-sided, and results were considered statistically significant ifP < .05. Because of the potential for type I error due to multiple comparisons in the observational studies, findings for the meta-analysis should be interpreted as exploratory.

Strength of Evidence

The strength of evidence was assessed by using modified GRADE criteria (eMethods inSupplement).²³ Ratings were based on study limitations (low, medium, or high level), consistency (consistent, inconsistent, or unknown/not applicable), directness (direct or indirect), precision (precise or imprecise), and reporting bias (suspected or undetected). The strength of evidence was assigned an overall grade of high, moderate, low, or insufficient by evaluating and weighing the combined results of the above domains. Grades were initially assessed by 1 investigator and then reviewed by all investigators for consensus.

Maternal Depression

Twenty-three studies reported adjusted estimates of the association between unintended pregnancy and maternal depression including 15 studies of depression during pregnancy (7 cohort^{24,28,29,31,32,34,37} and 8 cross-sectional^{39,44,49,50,51,55,56,58} studies) and 10 studies of depression post partum (4 cohort^24,27,30,37 and 6 cross-sectional^{19,41,42,43,47,48} studies) (Table 1). For prenatal depression, 12 studies collected depression measures during pregnancy^{28,29,31,32,34,37,49,50,51,55,56,58} and 3 collected measures post partum.^24,39,44 Maternal depression was defined by dichotomizing responses based on standardized depression instruments, including the Edinburgh Postnatal Depression Scale, Patient Health Questionnaire, Center for Epidemiological Studies Depression Scale, 6-item Kessler Psychological Distress Scale, Hopkins Symptom Checklist–Depression Scale, and World Mental Health Composite International Diagnostic Interview; relevant responses from the PRAMS; and direct questions about depression. These measures varied in their ability to identify symptoms of depression, screening thresholds for depression, or depression diagnosis.

In a meta-analysis, unintended compared with intended pregnancy was significantly associated with depression during pregnancy (23.3% vs 13.9%; adjusted odds ratio [aOR], 1.59 [95% CI, 1.35-1.92];I² = 85.0%; 15 studies [n = 41 054]^{24,28,29,31,32,34,37,39,44,49,50,51,55,56,58}) and post partum (15.7% vs 9.6%; aOR, 1.51 [95% CI, 1.40-1.70];I² = 7.1%; 10 studies [n = 82 673]^{19,24,27,30,37,41,42,43,47,48}) (Figure 2). In a sensitivity analysis, results were similar regardless of controlling for a history of depression, cross-sectional or cohort study design (eFigure 1 inSupplement), or whether the exposure of interest was defined by the study as an unwanted pregnancy rather than an unintended or unplanned pregnancy (eFigure 2 inSupplement). For studies comparing pregnancies occurring sooner than wanted,^{34,39,41,42,47,48,50} point estimates were consistent with the main findings, although not statistically significant for prenatal depression^34,39,50 (eFigure 3 inSupplement).

Maternal Experience of Interpersonal Violence

Five cross-sectional studies^{20,43,52,53,57} reported estimates of the relationship of unintended pregnancy and experience of interpersonal violence during pregnancy that adjusted for sociodemographic and other confounders. Two studies collected measures during pregnancy^52,57 and 3 post partum.^20,43,53 Violence was defined by dichotomizing responses based on standardized scales including the Life Stressor Checklist–Revised and NorVold Abuse Questionnaire; relevant items in the PRAMS; or a screening instrument validated for the study population.⁵⁹ Some measures included emotional or sexual abuse and used composite measures. In a meta-analysis, unintended compared with intended pregnancy was significantly associated with interpersonal violence during pregnancy (14.6% vs 5.5%; aOR, 2.22 [95% CI, 1.41-2.91];I² = 64.1%; 5 studies [n = 42 306]^{20,43,52,53,57}) (Figure 2). No sensitivity analysis was performed because all studies used a cross-sectional study design and defined the exposure of interest as a pregnancy that was unintended or unplanned.

Preterm Birth and Infant Low Birth Weight

Ten studies reported adjusted estimates of associations between unintended pregnancy and preterm birth, defined as less than 37 weeks’ completed gestation (4 cohort^26,33,35,36 and 6 cross-sectional^{19,38,40,43,45,54} studies). Eight studies reported infant low birth weight, measured as less than 2500 g (3 cohort^25,26,36 and 5 cross-sectional^{19,40,43,45,54} studies) (Table 2). Outcome measures were obtained from medical records, birth certificates, and parent self-report.

In a meta-analysis, unintended compared with intended pregnancy was significantly associated with preterm birth (9.4% vs 7.7%; aOR, 1.21 [95% CI, 1.12-1.31];I² = 1.7%; 10 studies [n = 94 351]^{19,26,33,35,36,38,40,43,45,54}) and infant low birth weight (7.3% vs 5.2%; aOR, 1.09 [95% CI, 1.02-1.21];I² = 0.0%; 8 studies [n = 87 547]^{19,25,26,36,40,43,45,54}) (Figure 3). In a sensitivity analysis, results for preterm birth were similar regardless of cross-sectional or cohort study design or whether the exposure of interest was defined by the study as a pregnancy that was unwanted rather than unintended or unplanned (eFigure 4 inSupplement). For infant low birth weight, point estimates were consistent with the main findings but were not statistically significant for cohort studies, or for pregnancies defined as unwanted, based on fewer studies (eFigure 5 inSupplement). For studies comparing pregnancies occurring sooner than wanted,^26,38,45 point estimates indicated that mistimed pregnancies compared with intended pregnancies were associated with lower odds of preterm birth and infant low birth weight, although few studies were included in these estimates (eFigure 4 and eFigure 5 inSupplement).

Publication Bias and Strength of Evidence

An assessment of publication bias indicated no small study effects for depression during pregnancy and post partum and for preterm birth (eFigure 6 inSupplement). There were too few studies to evaluate small study effects for interpersonal violence and low birth weight.

Studies met modified GRADE criteria for moderate to high strength of evidence of associations of unintended pregnancy with higher rates of maternal depression during pregnancy and post partum, maternal experience of interpersonal violence, preterm birth, and infant low birth weight (eTable inSupplement). These grades were supported by evidence that included data from large population-based sources with high applicability to clinical practices serving similar patient populations in the US, consistency and precision of findings, and unlikely reporting bias.

Limitations

This study has several limitations. First, only English-language articles and studies applicable to the US were included, although this focus improved its relevance to US clinical practice and public health. Compared with other high-income countries, the US has a higher rate of unintended pregnancy,⁸⁴ and health care financing and delivery differ greatly.

Second, this review was subject to publication bias in which studies with negative or null findings were not included because they were never published. While no small study effects were detected for depression during pregnancy and post partum and for preterm birth, publication bias remains a possibility.

Third, this review had a narrow scope and the meta-analysis included only 5 maternal and infant health outcomes. Several additional adverse pregnancy outcomes are associated with unintended pregnancy, such as higher rates of miscarriage,⁸⁵ premature rupture of membranes,⁴⁵ and complications during delivery,¹⁹ although fewer studies of these outcomes have been published. Other outcomes outside the scope of this review included long-term health, child development, and socioeconomic effects that can provide a more complete picture of adverse outcomes related to unintended pregnancy. However, previous reviews with broader scopes have noted a lack of research on additional maternal, infant, and child outcomes, particularly long-term outcomes.^3,60,86

Fourth, included studies were limited by the inconsistency and imprecision of their measures. Studies used several measures of unintended pregnancy including unwanted, unintended, mistimed, and attitudes about pregnancy, among others, and most studies relied on recall of pregnancy intention, introducing bias. Studies of maternal depression and violence used different outcome measures and time points. While some studies used validated scales for outcomes, others used investigator-generated measures. Despite these differences, results of studies were generally consistent regardless of measures used and supported results of previous systematic and narrative reviews.

Fifth, the inherent biases of observational studies that constitute the evidence base for this topic limit interpretations. Although inclusion criteria for this review required adjustment for confounders, studies varied in how well they accomplished this.

• 1.Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008-2011. N Engl J Med. 2016;374(9):843-852. doi: 10.1056/NEJMsa1506575 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 2.National Center for Health Statistics, Centers for Disease Control and Prevention . Key statistics from the National Survey of Family Growth – I listing. Accessed September 15, 2022.https://www.cdc.gov/nchs/nsfg/key_statistics/i-keystat.htm#intendbirthbywomen
• 3.Gipson JD, Koenig MA, Hindin MJ. The effects of unintended pregnancy on infant, child, and parental health: a review of the literature. Stud Fam Plann. 2008;39(1):18-38. doi: 10.1111/j.1728-4465.2008.00148.x [DOI] [PubMed] [Google Scholar]
• 4.American College of Obstetricians and Gynecologists . Committee opinion no. 615: access to contraception. Obstet Gynecol. 2015;125(1):250-255. doi: 10.1097/01.AOG.0000459866.14114.33 [DOI] [PubMed] [Google Scholar]
• 5.US Department of Health and Human Services . Healthy People 2030: pregnancy and childbirth. Accessed September 15, 2022.https://health.gov/healthypeople/objectives-and-data/browse-objectives/pregnancy-and-childbirth
• 6.Centers for Medicare & Medicaid Services . Birth control benefits. Accessed September 15, 2022.https://www.healthcare.gov/coverage/birth-control-benefits/
• 7.Curtis KM, Jatlaoui TC, Tepper NK, et al. US selected practice recommendations for contraceptive use, 2016 (US SPR). MMWR Recomm Rep. 2016;65(4):1-66. doi: 10.15585/mmwr.rr6504a1 [DOI] [PubMed] [Google Scholar]
• 8.Centers for Disease Control Prevention . US medical eligibility criteria for contraceptive use, 2010: practice guideline. MMWR Morb Mortal Wkly Rep. 2010;59(RR-4):1-86.20075837 [Google Scholar]
• 9.Gavin L, Pazol K. Update: providing quality family planning services: recommendations from CDC and the US Office of Population Affairs, 2015: practice guideline. MMWR Morb Mortal Wkly Rep. 2016;65(9):231-234. doi: 10.15585/mmwr.mm6509a3 [DOI] [PubMed] [Google Scholar]
• 10.Women’s Preventive Services Initiative . Contraception. Accessed September 15, 2022.https://www.womenspreventivehealth.org/recommendations/contraception
• 11.Frederiksen B, Ranji U, Salganicoff A, Long M. Women's sexual and reproductive health services: key findings from the 2020. KFF Women's Health Survey. Kaiser Family Foundation. Accessed September 15, 2022.https://www.kff.org/womens-health-policy/issue-brief/womens-sexual-and-reproductive-health-services-key-findings-from-the-2020-kff-womens-health-survey/
• 12.Sonfield A. Seeing the whole pattern: coordinated federal attacks on birth control coverage and access. Guttmacher Institute. Accessed September 15, 2022.https://www.guttmacher.org/article/2020/06/seeing-whole-pattern-coordinated-federal-attacks-birth-control-coverage-and-access
• 13.Guttmacher Institute . An overview of abortion laws. Accessed September 15, 2022.https://www.guttmacher.org/state-policy/explore/overview-abortion-laws
• 14.Nelson HD, Cantor A, Jungbauer RM, et al. Effectiveness and harms of contraceptive counseling and provision interventions for women. Ann Intern Med. 2022;175(7):980-993. doi: 10.7326/M21-4380 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 15.National Institute for Health Research . PROSPERO: international prospective register of systematic reviews. Accessed September 15, 2021.https://www.crd.york.ac.uk/prospero/
• 16.Effective Health Care Program, Agency for Healthcare Research and Quality . Methods guide for effectiveness and comparative effectiveness reviews. February 23, 2018. Accessed September 15, 2022.https://effectivehealthcare.ahrq.gov/products/collections/cer-methods-guide
• 17.Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000;283(15):2008-2012. doi: 10.1001/jama.283.15.2008 [DOI] [PubMed] [Google Scholar]
• 18.US Preventive Services Task Force . Methods and processes. Accessed September 15, 2022.https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes
• 19.McCrory C, McNally S. The effect of pregnancy intention on maternal prenatal behaviours and parent and child health: results of an Irish cohort study. Paediatr Perinat Epidemiol. 2013;27(2):208-215. doi: 10.1111/ppe.12027 [DOI] [PubMed] [Google Scholar]
• 20.Goodwin MM, Gazmararian JA, Johnson CH, Gilbert BC, Saltzman LE. Pregnancy intendedness and physical abuse around the time of pregnancy: findings from the pregnancy risk assessment monitoring system, 1996-1997: PRAMS Working Group: Pregnancy Risk Assessment Monitoring System. Matern Child Health J. 2000;4(2):85-92. doi: 10.1023/A:1009566103493 [DOI] [PubMed] [Google Scholar]
• 21.Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539-1558. doi: 10.1002/sim.1186 [DOI] [PubMed] [Google Scholar]
• 22.Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629-634. doi: 10.1136/bmj.315.7109.629 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 23.Berkman ND, Lohr KN, Ansari MT, et al. Grading the strength of a body of evidence when assessing health care interventions: an EPC update. J Clin Epidemiol. 2015;68(11):1312-1324. doi: 10.1016/j.jclinepi.2014.11.023 [DOI] [PubMed] [Google Scholar]
• 24.Bahk J, Yun SC, Kim YM, Khang YH. Impact of unintended pregnancy on maternal mental health: a causal analysis using follow up data of the Panel Study on Korean Children (PSKC). BMC Pregnancy Childbirth. 2015;15:85. doi: 10.1186/s12884-015-0505-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 25.Joyce TJ, Kaestner R, Korenman S. The effect of pregnancy intention on child development. Demography. 2000;37(1):83-94. doi: 10.2307/2648098 [DOI] [PubMed] [Google Scholar]
• 26.Lindberg L, Maddow-Zimet I, Kost K, Lincoln A. Pregnancy intentions and maternal and child health: an analysis of longitudinal data in Oklahoma. Matern Child Health J. 2015;19(5):1087-1096. doi: 10.1007/s10995-014-1609-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 27.Abbasi S, Chuang CH, Dagher R, Zhu J, Kjerulff K. Unintended pregnancy and postpartum depression among first-time mothers. J Womens Health (Larchmt). 2013;22(5):412-416. doi: 10.1089/jwh.2012.3926 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 28.Bayrampour H, McDonald S, Tough S. Risk factors of transient and persistent anxiety during pregnancy. Midwifery. 2015;31(6):582-589. doi: 10.1016/j.midw.2015.02.009 [DOI] [PubMed] [Google Scholar]
• 29.Bunevicius R, Kusminskas L, Bunevicius A, Nadisauskiene RJ, Jureniene K, Pop VJ. Psychosocial risk factors for depression during pregnancy. Acta Obstet Gynecol Scand. 2009;88(5):599-605. doi: 10.1080/00016340902846049 [DOI] [PubMed] [Google Scholar]
• 30.Chan KL. The role of father involvement and intimate partner violence on postnatal depression among women with unintended pregnancy. J Interpers Violence. 2021;36(17-18):NP9864-NP9884. doi: 10.1177/0886260519862274 [DOI] [PubMed] [Google Scholar]
• 31.Chee CY, Lee DT, Chong YS, Tan LK, Ng TP, Fones CS. Confinement and other psychosocial factors in perinatal depression: a transcultural study in Singapore. J Affect Disord. 2005;89(1-3):157-166. doi: 10.1016/j.jad.2005.09.004 [DOI] [PubMed] [Google Scholar]
• 32.Gariepy AM, Lundsberg LS, Miller D, Stanwood NL, Yonkers KA. Are pregnancy planning and pregnancy timing associated with maternal psychiatric illness, psychological distress and support during pregnancy?J Affect Disord. 2016;205:87-94. doi: 10.1016/j.jad.2016.06.058 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 33.Gariepy AM, Lundsberg LS, Stolar M, Stanwood NL, Yonkers KA. Are pregnancy planning and timing associated with preterm or small for gestational age births?Fertil Steril. 2015;104(6):1484-1492. doi: 10.1016/j.fertnstert.2015.08.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 34.Maxson P, Miranda ML. Pregnancy intention, demographic differences, and psychosocial health. J Womens Health (Larchmt). 2011;20(8):1215-1223. doi: 10.1089/jwh.2010.2379 [DOI] [PubMed] [Google Scholar]
• 35.Orr ST, Miller CA, James SA, Babones S. Unintended pregnancy and preterm birth. Paediatr Perinat Epidemiol. 2000;14(4):309-313. doi: 10.1046/j.1365-3016.2000.00289.x [DOI] [PubMed] [Google Scholar]
• 36.Phipps MG, Nunes AP. Assessing pregnancy intention and associated risks in pregnant adolescents. Matern Child Health J. 2012;16(9):1820-1827. doi: 10.1007/s10995-011-0928-0 [DOI] [PubMed] [Google Scholar]
• 37.Rich-Edwards JW, Kleinman K, Abrams A, et al. Sociodemographic predictors of antenatal and postpartum depressive symptoms among women in a medical group practice. J Epidemiol Community Health. 2006;60(3):221-227. doi: 10.1136/jech.2005.039370 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 38.Afable-Munsuz A, Braveman P. Pregnancy intention and preterm birth: differential associations among a diverse population of women. Perspect Sex Reprod Health. 2008;40(2):66-73. doi: 10.1363/4006608 [DOI] [PubMed] [Google Scholar]
• 39.Fellenzer JL, Cibula DA. Intendedness of pregnancy and other predictive factors for symptoms of prenatal depression in a population-based study. Matern Child Health J. 2014;18(10):2426-2436. doi: 10.1007/s10995-014-1481-4 [DOI] [PubMed] [Google Scholar]
• 40.Flower A, Shawe J, Stephenson J, Doyle P. Pregnancy planning, smoking behaviour during pregnancy, and neonatal outcome: UK Millennium Cohort Study. BMC Pregnancy Childbirth. 2013;13:238. doi: 10.1186/1471-2393-13-238 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 41.Gauthreaux C, Negron J, Castellanos D, et al. The association between pregnancy intendedness and experiencing symptoms of postpartum depression among new mothers in the United States, 2009 to 2011: a secondary analysis of PRAMS data. Medicine (Baltimore). 2017;96(6):e5851. doi: 10.1097/MD.0000000000005851 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 42.Gross KH, Wells CS, Radigan-Garcia A, Dietz PM. Correlates of self-reports of being very depressed in the months after delivery: results from the Pregnancy Risk Assessment Monitoring System. Matern Child Health J. 2002;6(4):247-253. doi: 10.1023/A:1021110100339 [DOI] [PubMed] [Google Scholar]
• 43.Mark NDE, Cowan SK. Do pregnancy intentions matter? a research note revisiting relationships among pregnancy, birth, and maternal outcomes. Demography. 2022;59(1):37-49. doi: 10.1215/00703370-9710311 [DOI] [PubMed] [Google Scholar]
• 44.Moreau C, Bonnet C, Beuzelin M, Blondel B. Pregnancy planning and acceptance and maternal psychological distress during pregnancy: results from the National Perinatal Survey, France, 2016. BMC Pregnancy Childbirth. 2022;22(1):162. doi: 10.1186/s12884-022-04496-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 45.Mohllajee AP, Curtis KM, Morrow B, Marchbanks PA. Pregnancy intention and its relationship to birth and maternal outcomes. Obstet Gynecol. 2007;109(3):678-686. doi: 10.1097/01.AOG.0000255666.78427.c5 [DOI] [PubMed] [Google Scholar]
• 46.Centers for Disease Control and Prevention . Participating PRAMS sites. Accessed September 15, 2022.https://www.cdc.gov/prams/states.htm
• 47.Cheng D, Schwarz EB, Douglas E, Horon I. Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors. Contraception. 2009;79(3):194-198. doi: 10.1016/j.contraception.2008.09.009 [DOI] [PubMed] [Google Scholar]
• 48.Suh EY, Ma P, Dunaway LF, Theall KP. Pregnancy intention and post-partum depressive affect in Louisiana pregnancy risk assessment monitoring system. Matern Child Health J. 2016;20(5):1001-1013. doi: 10.1007/s10995-015-1885-9 [DOI] [PubMed] [Google Scholar]
• 49.Cruz-Bendezú AM, Lovell GV, Roche B, et al. Psychosocial status and prenatal care of unintended pregnancies among low-income women. BMC Pregnancy Childbirth. 2020;20(1):615. doi: 10.1186/s12884-020-03302-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 50.Blake SM, Kiely M, Gard CC, El-Mohandes AA, El-Khorazaty MN; NIH-DC Initiative . Pregnancy intentions and happiness among pregnant black women at high risk for adverse infant health outcomes. Perspect Sex Reprod Health. 2007;39(4):194-205. doi: 10.1363/3919407 [DOI] [PubMed] [Google Scholar]
• 51.Dudas RB, Csatordai S, Devosa I, et al. Obstetric and psychosocial risk factors for depressive symptoms during pregnancy. Psychiatry Res. 2012;200(2-3):323-328. doi: 10.1016/j.psychres.2012.04.017 [DOI] [PubMed] [Google Scholar]
• 52.Lukasse M, Laanpere M, Karro H, et al. ; Bidens Study Group . Pregnancy intendedness and the association with physical, sexual and emotional abuse: a European multi-country cross-sectional study. BMC Pregnancy Childbirth. 2015;15:120. doi: 10.1186/s12884-015-0558-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 53.Narayan AJ, Hagan MJ, Cohodes E, Rivera LM, Lieberman AF. Early childhood victimization and physical intimate partner violence during pregnancy: a developmental and person-oriented approach. J Interpers Violence. 2019;34(1):3-26. doi: 10.1177/0886260516639261 [DOI] [PubMed] [Google Scholar]
• 54.Hohmann-Marriott B. The couple context of pregnancy and its effects on prenatal care and birth outcomes. Matern Child Health J. 2009;13(6):745-754. doi: 10.1007/s10995-009-0467-0 [DOI] [PubMed] [Google Scholar]
• 55.Dhillon N, Macarthur C. Antenatal depression and male gender preference in Asian women in the UK. Midwifery. 2010;26(3):286-293. doi: 10.1016/j.midw.2008.09.001 [DOI] [PubMed] [Google Scholar]
• 56.Escribè-Agüir V, Gonzalez-Galarzo MC, Barona-Vilar C, Artazcoz L. Factors related to depression during pregnancy: are there gender differences?J Epidemiol Community Health. 2008;62(5):410-414. doi: 10.1136/jech.2007.063016 [DOI] [PubMed] [Google Scholar]
• 57.Martin KR, Garcia L. Unintended pregnancy and intimate partner violence before and during pregnancy among Latina women in Los Angeles, California. J Interpers Violence. 2011;26(6):1157-1175. doi: 10.1177/0886260510368154 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 58.Redshaw M, Henderson J. From antenatal to postnatal depression: associated factors and mitigating influences. J Womens Health (Larchmt). 2013;22(6):518-525. doi: 10.1089/jwh.2012.4152 [DOI] [PubMed] [Google Scholar]
• 59.Peek-Asa C, Garcia L, McArthur D, Castro R. Severity of intimate partner abuse indicators as perceived by women in Mexico and the United States. Women and Health. 2002;35:165-180. [DOI] [PubMed] [Google Scholar]
• 60.Hill B, Kothe EJ, Currie S, et al. A systematic mapping review of the associations between pregnancy intentions and health-related lifestyle behaviours or psychological wellbeing. Prev Med Rep. 2019;14:100869. doi: 10.1016/j.pmedr.2019.100869 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 61.Shah PS, Balkhair T, Ohlsson A, Beyene J, Scott F, Frick C. Intention to become pregnant and low birth weight and preterm birth: a systematic review. Matern Child Health J. 2011;15(2):205-216. doi: 10.1007/s10995-009-0546-2 [DOI] [PubMed] [Google Scholar]
• 62.Hall JA, Benton L, Copas A, Stephenson J. Pregnancy intention and pregnancy outcome: systematic review and meta-analysis. Matern Child Health J. 2017;21(3):670-704. doi: 10.1007/s10995-016-2237-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 63.Curry SJ, Krist AH, Owens DK, et al. ; US Preventive Services Task Force . Interventions to prevent perinatal depression: US Preventive Services Task Force recommendation statement. JAMA. 2019;321(6):580-587. doi: 10.1001/jama.2019.0007 [DOI] [PubMed] [Google Scholar]
• 64.Curry SJ, Krist AH, Owens DK, et al. ; US Preventive Services Task Force . Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: US Preventive Services Task Force final recommendation statement. JAMA. 2018;320(16):1678-1687. doi: 10.1001/jama.2018.14741 [DOI] [PubMed] [Google Scholar]
• 65.Women’s Preventive Services Initiative . Screening for interpersonal and domestic violence. Accessed September 15, 2022.https://www.womenspreventivehealth.org/recommendations/screening-for-interpersonal-and-domestic-violence/
• 66.Norhayati MN, Hazlina NH, Asrenee AR, Emilin WM. Magnitude and risk factors for postpartum symptoms: a literature review. J Affect Disord. 2015;175:34-52. doi: 10.1016/j.jad.2014.12.041 [DOI] [PubMed] [Google Scholar]
• 67.Lovejoy MC, Graczyk PA, O’Hare E, Neuman G. Maternal depression and parenting behavior: a meta-analytic review. Clin Psychol Rev. 2000;20(5):561-592. doi: 10.1016/S0272-7358(98)00100-7 [DOI] [PubMed] [Google Scholar]
• 68.Szegda K, Markenson G, Bertone-Johnson ER, Chasan-Taber L. Depression during pregnancy: a risk factor for adverse neonatal outcomes? a critical review of the literature. J Matern Fetal Neonatal Med. 2014;27(9):960-967. doi: 10.3109/14767058.2013.845157 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 69.Wouk K, Stuebe AM, Meltzer-Brody S. Postpartum mental health and breastfeeding practices: an analysis using the 2010-2011 Pregnancy Risk Assessment Monitoring System. Matern Child Health J. 2017;21(3):636-647. doi: 10.1007/s10995-016-2150-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 70.Beck CT. The effects of postpartum depression on child development: a meta-analysis. Arch Psychiatr Nurs. 1998;12(1):12-20. doi: 10.1016/S0883-9417(98)80004-6 [DOI] [PubMed] [Google Scholar]
• 71.Minkovitz CS, Strobino D, Scharfstein D, et al. Maternal depressive symptoms and children’s receipt of health care in the first 3 years of life. Pediatrics. 2005;115(2):306-314. doi: 10.1542/peds.2004-0341 [DOI] [PubMed] [Google Scholar]
• 72.Santos IS, Matijasevich A, Barros AJ, Barros FC. Antenatal and postnatal maternal mood symptoms and psychiatric disorders in pre-school children from the 2004 Pelotas Birth Cohort. J Affect Disord. 2014;164(100):112-117. doi: 10.1016/j.jad.2014.04.033 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 73.Smith SG, Zhang X, Basile KC, et al. The National Intimate Partner and Sexual Violence Survey: 2015 data brief: updated release. November 2018. Accessed September 15, 2022.https://stacks.cdc.gov/view/cdc/60893
• 74.Shah PS, Shah J; Knowledge Synthesis Group on Determinants of Preterm/LBW Births . Maternal exposure to domestic violence and pregnancy and birth outcomes: a systematic review and meta-analyses. J Womens Health (Larchmt). 2010;19(11):2017-2031. doi: 10.1089/jwh.2010.2051 [DOI] [PubMed] [Google Scholar]
• 75.Desmarais SL, Pritchard A, Lowder EM, Janssen PA. Intimate partner abuse before and during pregnancy as risk factors for postpartum mental health problems. BMC Pregnancy Childbirth. 2014;14:132. doi: 10.1186/1471-2393-14-132 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 76.Pavey AR, Gorman GH, Kuehn D, Stokes TA, Hisle-Gorman E. Intimate partner violence increases adverse outcomes at birth and in early infancy. J Pediatr. 2014;165(5):1034-1039. doi: 10.1016/j.jpeds.2014.06.060 [DOI] [PubMed] [Google Scholar]
• 77.American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics . Prediction and prevention of spontaneous preterm birth: ACOG Practice Bulletin, Number 234. Obstet Gynecol. 2021;138(2):e65-e90. doi: 10.1097/AOG.0000000000004479 [DOI] [PubMed] [Google Scholar]
• 78.Manuck TA. Racial and ethnic differences in preterm birth: a complex, multifactorial problem. Semin Perinatol. 2017;41(8):511-518. doi: 10.1053/j.semperi.2017.08.010 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 79.Campbell DE, Imaizumi SO. Health and developmental outcomes of very preterm and very low-birth-weight infants. In: McInerny TK, Adam HM, Campbell DE, DeWitt TG, Meschan Foy J, Kamat DM, eds. American Academy of Pediatrics Textbook of Pediatric Care. American Academy of Pediatrics; 2016. [Google Scholar]
• 80.Stewart DL, Barfield WD; Committee on Fetus and Newborn . Updates on an at-risk population: late-preterm and early-term infants. Pediatrics. 2019;144(5):e20192760. doi: 10.1542/peds.2019-2760 [DOI] [PubMed] [Google Scholar]
• 81.Rocca CH, Ralph LJ, Wilson M, Gould H, Foster DG. Psychometric evaluation of an instrument to measure prospective pregnancy preferences: the desire to avoid pregnancy scale. Med Care. 2019;57(2):152-158. doi: 10.1097/MLR.0000000000001048 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 82.Kost K, Zolna M. Challenging unintended pregnancy as an indicator of reproductive autonomy: a response. Contraception. 2019;100(1):5-9. doi: 10.1016/j.contraception.2019.04.010 [DOI] [PubMed] [Google Scholar]
• 83.Potter JE, Stevenson AJ, Coleman-Minahan K, et al. Challenging unintended pregnancy as an indicator of reproductive autonomy. Contraception. 2019;100(1):1-4. doi: 10.1016/j.contraception.2019.02.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
• 84.Singh S, Sedgh G, Hussain R. Unintended pregnancy: worldwide levels, trends, and outcomes. Stud Fam Plann. 2010;41(4):241-250. doi: 10.1111/j.1728-4465.2010.00250.x [DOI] [PubMed] [Google Scholar]
• 85.Nguyen BT, Chang EJ, Bendikson KA. Advanced paternal age and the risk of spontaneous abortion: an analysis of the combined 2011-2013 and 2013-2015 National Survey of Family Growth. Am J Obstet Gynecol. 2019;221(5):476.e1-476.e7. doi: 10.1016/j.ajog.2019.05.028 [DOI] [PubMed] [Google Scholar]
• 86.Logan C, Holcombe E, Manlove J, Ryan S. The consequences of unintended childbearing: a white paper. Child Trends. May 1, 2007. Accessed October 5, 2022.https://www.childtrends.org/publications/the-consequences-of-unintended-childbearing-a-white-paper

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